The challenges of improving access to sexual health services to improve the sexual health of the nation

Abstract

This research study is set within the national context of deteriorating sexual health. It is an attempt to discover the issues and influences behind the modelling of NHS sexual health services and what is made available to the service users. These services are having difficulty meeting the high demands of the public and achieving government targets that have been placed upon them to tackle the unprecedented rise in levels of diagnosed infection and prevent unintended conceptions. A qualitative survey of professionals and client discourse was the design for the fieldwork, consisting of interviews and focus groups of sexual health service leads, practitioners and service users, a total of 89 voices. These were analysed within a framework of feminist and complexity theory. This research exposed that the services themselves have historically experienced serious marginalisation. This has affected allocation of resources and maintained a closed shop culture, which, unless changed, allows little room for improvement. This issue is well known and yet allowed to remain hidden. The findings demonstrate that the "top to toe modernisation of the NHS", stated within the NHS plan 2000 (DH), is not greatly evident within sexual health services over 2005 to 2006, when the fieldwork was carried out. The services have not, in most cases, been redesigned around the needs of patients, access has not been improved and the roles of nurses in many services have not been extended to address these access issues, but in some cases actually blocked from doing so. The Modernisation Agency has had little effect. Service users have not felt the effect of the devolved power promised so they could have influence and service providers are not often centred on them. Attempts to improve this situation are frequently thwarted by poor strategic planning and obstruction by senior clinical staff, who fear loss of position or power. Alongside this there was evidence of insufficient workforce fit for purpose, including commissioners, key to these developments. Where services were shown to be aiming to modernise and develop integrated models of provision, this came from a strong ethos of having service users at the centre of care anda vision to improve access and quality of provision. NHS Health trusts are not allowing sexual health to be centre stage. Any improvements in services will not be sustained without a change in culture within these services themselves, as well as within the wider NHS and society generally. Investigation of theactual quality of service provision and what the public want requires a national research driver. The insider role of the researcher created opportunities to capture stories that would otherwise have been missed by an outsider. This allowed debunking or demystifying some outdated views of the functioning of sexual health service provision and the reasons for their lack of progress. The complexity theory framework gave a frame of reference for why services function the way they do, either as silo-centred or transformed. It also illustrated that forcing structural changes or service redesign, within a top down approach will not achieve a whole systems transformation. An integrated sexual health service model was demonstrated as a complex system that allowed transformation to evolve where there was success in impacting patterns of thinking, behaviour and values of the service providers. These micro-patterns allowed a rich complexity to emerge bringing positive outcomes and maybe even supporting government targets as more new patterns emerge. This was opposite to silo-centred thinking, evident in the more traditional settings. Modernisation processes and normalisation of sexual health services, alongside integration, would be assisted using complexity principles.